Galesburg High School is committed to creating a safe, supportive, and positive environment for students to obtain a quality education. School incidents involving bullying are taken very seriously at GHS. When these incidents are reported, support services can be provided to all students involved.

As stated in the GHS Code of Student Conduct Book (page 5), bullying is defined as any severe or pervasive physical or verbal act or conduct, including communications made in writing or electronically, directed toward a student that has or can be reasonably predicted to have the effect of one or more of the following: 1. Placing the student in reasonable fear of harm to the student's person or property. 2. Causing a substantially detrimental effect on the student's physical or mental health. 3. Substantially interfering with the student's academic performance. 4, Substantially interfering with the student's ability to participate in or benefit from the services, activities, or privileges provided by a school.

This form has been created to help provide a safe means of reporting an incident of bullying to school personnel. It is designed to remain anonymous, and it encourages bystanders of bullying incidents to report their observations so appropriate action can be taken. Victims of bullying and witnesses are also encouraged to use this form, as well as report the incident directly to the staff at GHS.

* Required

Your Name *

If you do not list your name we cannot look into the incident

Your answer

Indicate here if you prefer to remain anonymous. *

Yes

No

Date of Incident *

MM

/

DD

/

YYYY

Time

:

AM

PM

Who is being bullied or harrassed? *

I am

Another person

You are a: *

Student

Parent

Staff member

Other:

Student(s) were targeted for bullying in the following way(s). (Check all that apply.) *

1. You may be contacted by either administration, counselors, or police.2. School personnel will investigate and may require addition information from the individual submitting the report.3. If you feel you are in immediate danger, please contact the authorities as soon as possible.